Consultation Analysis

The consultation is the basic tool of general practice but like the discipline it has changed much over the past 50 years. In the 1950s patients did not have appointments but came and waited to be seen. A doctor might see 40 patients in their morning surgery, do 30 or 40 home visits and then see that number again in their evening surgery. It was a treadmill with little time for niceties and the record of a consultation rarely extended beyond one line of the Lloyd George notes.

The 1960s and 1970s saw the advent of appointments with each patient allocated 5 minutes but with time that was extended to 7.5 minutes and now the qualities and outcomes framework insists on at least 10 minutes each. Interestingly, some research suggest that "long is good, short is bad" in terms of length of consultation, is probably not strictly true.¹ In one study in UK average consultation lengths were 8 minutes which were increased by 1 minute in patients with psychosocial problems - but this was enough to improve quality of care.² Patients continue to express dissatisfaction with time spent with their GP. Although, this can be improved possibly by increasing the length of consultations, it may be better to improve the way in which the consultation is spent.³

In medical school students are taught to diagnose disease with the basic template of history, examination and investigations, but analysis of the consultation takes a much more profound view of why the patient came and what has been achieved in the consultation.

Analysis of the consultation has evolved and will continue to evolve. In 1957 Michael Balint published "The doctor, the patient and his illness". In 1977 the RCGP defined general practice in a way that includes consideration of the physical, psychological and social condition of the patient. One of the greatest influences was not a GP but a social psychologist. David Pendleton wrote his PhD thesis on analysis of the consultation but he did this in association with a number of GPs in the Oxford Region and he used the newly available medium of video recording consultations. This was a very incisive and revealing technique that even psychiatrists were slow to follow and because it is so revealing certain safeguards must be applied. Video recording of consultations for analysis by one's peers is now a standard part of the training of registrars and a requirement for MRCGP by examination or by assessment of performance as well as FRCGP by assessment.

Of particular note, a large number of medical schools in the UK now use the Calgary Cambridge method of analysing consultations.^4,5 This method builds on and has taken the Pendleton approach to the next level.

Rules for video recording of consultations: because the medium is so revealing and intrudes into the privacy of the doctor/ patient relationship, there are certain rules that must be applied:

• The camera should be set up in such a way that it captures the patient's face and expressions and preferably includes the doctor too.
• The size of consulting rooms permitted under the old red book did not allow for video recording or a larger desk to accommodate a computer.
• The direction of the camera should be such that during examination the intimate parts of the patient's anatomy are not revealed. Otherwise it may be necessary to pause it.
• When the patient reports to reception they should be told that the doctor is recording the surgery for the purpose of training and that he would appreciate the patient's consent to include their consultation.
• The patient is offered a consent form that should include a brief explanation of what is involved including who will view the recording, explain that if the patient does not wish to be recorded that the appointment will proceed without prejudice and that if they should change their mind at any stage the camera will be switched off and that section erased.
• As the patient enters the room the doctor greets him and asks for the consent form. If there is consent he continues. If not he switches off the camera. Some people like the patient to sign a second time at the end of the consultation. Remarkably few people refuse consent to record the consultation.
• The tape should be played only to an audience of one's peers. If it is sent to the RCGP for the purpose of examination it will be marked according to a preordained schedule. If it is for the purpose of education it is viewed by a small group, or perhaps just the doctor and his trainer and the Pendleton rules apply.

Pendleton rules

These have been varied slightly over the years but basically they state the following:

• The first person to comment on the performance is the subject of the recording and they start by stating what they thought that they did well before moving on to aspects that might have been done better.⁶
• Then it is the turn of others but they too are compelled to start by enumerating the good aspects before being allowed to become critical.⁶
• Areas for personal development may be identified.
• This technique is important to prevent hurt or a feeling of humiliation in the person who reveals his video.

The basic aims of the consultation as outlined by David Pendleton et al remain intact although they have been developed over the years by Roger Neighbour and Robin Fraser to name just a few. David Pendleton, Theo Schofield, Peter Tate and Peter Havelock developed 7 basic tasks:⁷

1. Define the reason for attendance: Including the history, the patient's ideas, concerns and expectations, and the effects of the problem. Why did the patient really come? Is there a false or unrealistic expectation? Are there fears that need to be allayed or other issues that need to be addressed? Is there a hidden agenda? Sometimes patients present with something grossly trivial and then proceed with "By the way doctor, while I'm here..." and proceed with the reason why they really came. This is very frustrating as time has been wasted on the irrelevance, often leaving inadequate time for the true agenda. If patients feel more at ease they may be able to present with their real concerns at the outset.
2. Consider other problems: Including continuing problems and risk factors. This might include health promotion and addressing risks like smoking or obesity. It could include problems like social conditions.
3. Choose an appropriate action: This is clinical management. It may be prescription, reassurance or referral. It may involve follow up. Analysis of the consultation is not simply about the psychosocial aspects but also checks that good clinical practice is being observed. Appropriate action may also include a relevant and competently conducted physical examination.
4. Achieve a shared understanding: It is important that the patient understands the disease, its aetiology and its treatment as this may improve compliance although the word compliance is regarded by some as derogatory and implying passive acquiescence and paternalism. The patient may need to know why it is important that certain lifestyles and habits are changed and the need to follow specific regimes of treatment. This puts a degree of responsibility on the patient.
5. Involve the patient in management: This may also be part of getting the patient to take responsibility or it may be a valid discussion about alternative approaches. 25 years ago, if a doctor tried to involve the patient in making decisions the patient would have said, "Well you're the doctor. You tell me." An elderly patient has atrial fibrillation. Should she have aspirin or warfarin? Shall we treat this osteoarthritis with NSAIDs, paracetamol or omit the drugs and just try to keep active? These are examples of valid alternatives and the patient's preference is important. Sometimes the evidence is so compelling that there is little to discuss but the patient may need to know this.
6. Use time and resources appropriately: This applies both during the consultation and long term. A 10 minutes consultation is not a long time and it must be used judiciously. Inefficient use of time might include unnecessary follow up or just being too meticulous, taking 20 to 30 minutes for every consultation and running unnecessarily late. Bad management may include irrelevance. Covering all the ground but doing so in the allotted time is most demanding.
7. Establish or maintain a relationship: The doctor/patient relationship remains crucial for successful medical practice. It is not as paternalistic as once it was but the patient has to trust the doctor and believe in mutual honesty. If the doctor seems disinterested, aloof or sanctimonious the patient will retreat. We do have a moral stance to maintain and we must not drop our personal values but it is not our place to pass judgement. Smile and radiate empathy. Always appear interested in the patient.

There are a number of skills to be developed and an open and self-critical approach will benefit the most.

1. Welcoming: Does the doctor encourage comfort and trust from the outset? Is the patient at ease and ready to bear their soul? Do not be finishing off the notes for the last patient when the next arrives. Check the records before the patient enters so as to be able to offer full and undivided attention. It may be mundane to you but to the patient this is the most important thing to have happened all week.
2. Questions: Questions should be open, giving the patient the opportunity to expand, not closed and limited or leading. In reality we sometimes have to break this rule to get a meaningful answer from certain people. Try not to interrupt unless for clarification although some people do need reining in. Listen and maintain a flow. Sometimes patients say something that needs further investigation but it is inappropriate to break the current chain of thought and focus. They should be returned to later in the consultation but it is very easy to forget until after the patient has left the room. A useful tip is to write a note to remind oneself before the patient leaves.
3. Listening: Appear attentive and maintain eye contact as much as possible. It may or may not be appropriate to make notes as the patient speaks. In the early days of computers patients used to complain, "He was more interested in that screen than in me." Listening includes looking and noting non-verbal cues and body language.
4. Response: This involves clarifying points, summarizing, reflecting statements and feelings, ascertaining understanding and possibly defusing anger. Empathy forms an important response and for some patients may be all that is required, thus forming a therapy as well.⁸
5. Explanation: Use language that the patient will understand. Give important information first. Possibly repeat important points and ascertain that the patient understands. Written information or visual aids may help too.
6. Closure: The closing act of an consultation used to be the issuing of a prescription and no consultation was complete without one. Some form of closure is required with clarification of what is expected of the patient or the next step. Make correct, adequate and contemporaneous notes.

Doctors talking to patients by Patrick Byrne and Barrie Long in 1976 was another example of analysis of the consultation. They divided it into 6 phases:

1. The doctor establishes a relationship with the patient.
2. The doctor attempts to discover the reason why the patient attended. This might not be as transparent as first it seems. What is the patient's agenda? What are their fears and concerns?
3. History and possibly examination occurs.
4. The doctor, in consultation with the patient, considers the condition.
5. Treatment or further investigations are discussed.
6. The doctor brings the consultation to a close.

The style of the consultation says as much about the personality of the doctor, or sometimes the patient. They described a spectrum ranging from a heavily doctor dominated consultation, with any contribution from the patient severely curtailed, to a virtual monologue by the patient with the doctor as a passive listener. There is a gradient of styles from closed information gathering to non-directive counselling, depending on whether the doctor was more interested in developing his own line of thought or that of the patient.

Developing one's consultation skills takes time, practice and much self criticism and self awareness. Making video recording of consultations is a very potent tool to examine them in detail later. At first the doctor, and as a result the patient, feel conscious about the presence of the camera but before long they relax and behave normally. Doctors who record regularly relax more rapidly. Even when the surgery is not being recorded it is worth pretending that it is and ascertaining that one acts at all times as if the surgery was for review by one's peers. This is like the Hawthorne effect, that just observing people makes them change their behaviour. There is far more to general practice than simply diagnosis and treatment. The good doctor is an excellent clinician with a good knowledge of medicine, diagnosis and management, but he will be better still for understanding the mechanisms of those complex interactions with patients. This aspects of consultation need to be considered and practised from the beginning of a doctors career i.e. as medical students and they apply not only primary care doctors but all doctors.¹⁰